Discussion
We demonstrated significant differences in sleep and mental health
measures between adults with AD and healthy controls. Using validated
questionnaires, the AD group reported poorer sleep quality and more
severe insomnia symptoms than the control participants. Our results
align with recent studies that showed lower sleep quality, higher sleep
disturbances, and a greater risk of insomnia in adult AD
patients5,38.
AD patients also presented more severe depressive symptoms than
controls. On the other hand, we did not observe a significant difference
in anxiety between the two groups. The current literature on the mental
health of the AD population seems consistent in showing high rates of
depression and anxiety in adults with AD compared to the general
population18,39. However, previous studies have found
conflicting results regarding whether AD is associated with increased
mental health disorders15.
Our results also showed higher levels of perceived stress in the AD
group compared with controls. Psychological stress has been identified
as a major aggravating factor in AD22. Similarly,
itching, discomfort, disfigurement, perceived social stigmatization,
isolation, poor quality of life, and sleep disturbances lead the AD
population to experience more psychological
distress2,40–42. However, comparative studies between
AD and healthy adults have not been reported.
The present study also showed that objective and subjective severity of
AD significantly predicted sleep quality and insomnia. More severe AD
was associated with worse sleep quality and greater insomnia symptoms.
Several recent studies also reported that sleep disturbances seem to
worsen with the severity of AD8,9,23,43. Moreover, our
results highlighted that, although objective and subjective disease
severity similarly predict sleep quality, patient-oriented subjective
severity of AD appeared to contribute more to the manifestation of
insomnia symptoms in AD adults.
AD patients may experience a significant amount of itching, pain, and
discomfort, which can lead to sleep disturbances6.
Although objective measures of AD provide a quantitative assessment of
the disorder, the subjective severity of AD may be a more complete and
accurate predictor of insomnia, taking into account the physical and
psychological factors of the condition.
To the same extent, objective and subjective severity of AD also
predicted anxiety symptoms and self-perceived stress. On the other hand,
the self-perceived severity of AD, but not the objective measure,
significantly predicted depressive symptoms. Therefore, anxiety and
stress symptoms of AD patients increased with increasing objective and
subjective severity of the disease. However, depressive symptoms
exhibited by AD adults were exclusively related to personal perception
of disease severity.
A recent study highlighted higher levels of self-perceived stress in
patients with severe AD 19, similar to our findings.
Two recent meta-analyses showed a significant positive association
between AD and anxiety and depression16,18. Silverberg
et al.15 found that patients with moderate and severe
AD had significantly worse mental health than those with mild AD. The
relation between the clinical severity of AD and psychological
well-being is central to clinician behaviour. When treating patients
with moderate-to-severe AD, dermatologists should be vigilant and screen
and refer to a specialist for psychiatric symptoms.
Recently, the absence of a causal role of AD in the development of
depressive and anxiety disorders has been proposed44,
supporting the existence of an indirect link between AD and
psychological measures driven by other concomitant conditions. In this
regard, recent studies suggested that sleep disturbances might
predispose AD patients to experience psychological
symptoms45,46.
Although the present study aligns with the recent literature, our
results suggest a different impact of objective and subjective AD
severity on the global disease burden. In clinical practice, there is a
wide discrepancy between patient-oriented subjective evaluation and
clinician-oriented measurement47. This could be
partially explained by physicians’ underestimation of the intensity of
symptoms. Moreover, the severity of AD partially depends on the personal
perception that individuals attribute to the
disorder25. Our results underline the importance of
using patient-oriented severity tools alongside objective indexes in
clinical and research practice.
Overall, AD appears to strongly affect the physical and mental
well-being of patients, with a considerable impact on sleep and
psychological health. However, the pathogenesis of sleep and
psychological disorders in AD patients is complex and not fully
understood4,14. Currently, there is a need for a
consensus guiding the evaluation and management of sleep and
psychological disorders in AD patients. In detail, most dermatological
investigations do not focus on evaluating sleep disorders, limiting the
management and treatment of these disturbances. Polysomnography and
actigraphy are objective and valid but impractical in dermatological
studies5. However, the use of self-administered
validated questionnaires could easily guarantee the evaluation of sleep
quality in AD patients5, also offering the possibility
to follow the time course of the disturbance. On the psychological side,
there are no specific tools designed for the psychological assessment of
AD patients in the clinical setting48. In addition to
an overall analysis of the patient’s quality of life, physicians and
researchers should also pay more attention to the specific psychological
symptoms exhibited by AD patients, such as depression, anxiety, and
psychological stress, which could exacerbate the severity of the skin
condition, triggering a vicious circle from which it is challenging to
get out16,18.
Our study has limitations. Our findings were obtained in a small
clinical sample undergoing different pharmacological treatments. The
assessment of insomnia, depression/anxiety symptoms, and stress using
self-reported tools might have produced a selection bias by including
only individuals able to complete questionnaires via a digital medium.
However, in our study, the use of electronic questionnaires at home was
well accepted by patients, reduced the risk of non-completion in waiting
or dedicated rooms, and minimized the risk of incomplete filling or
erroneous completion.
In conclusion, the present study showed poor sleep quality and high
levels of insomnia, depression, and perceived stress in AD patients,
highlighting a worse health context for individuals with greater disease
severity. The disease burden in AD is multifaceted and difficult to
estimate as in addition to the severity of the condition as represented
by clinical signs, poorer sleep quality, severe insomnia conditions, the
coexistence of underdiagnosed anxiety/depression symptoms, and impaired
stress responses are disease-specific symptoms that contribute to the
broad impact of the disease on patients’ life. Overall, our results
suggest the importance of adopting a multidisciplinary approach to the
management and treatment of patients with AD, ensuring an adequate
screening for sleep and psychological disorders, with particular
attention to personal perception of disease severity.